NP2 Mental Health HESI

SSRI's

----SSRI: Citalopram, Escitalopram, Fluoxetine, Fluvoxamine, Paroxetine, Sertraline · SE: headaches, GI disturbance , insomnia, fatigue, initial anxiety, sexual problems, agitation, increased bleeding risk, can also treat anxiety disorders · Can be treated with anti-arrythmic (Cardizem) and Beta-blockers -Severe manifestations can induce hyperpyrexia, CV shock coma or death. Their risk is greater when an SSRI is combined with a MAOI, and over the counter cold medications. -When switching between antidepressants, wash out 2-5 weeks -hyponatremia -increased bleeding tendencies -avoid alcohol and herbal medications

TCA

----TCA: Imipramine, Amitriptyline, Desipramine, Nortriptyline, Clomipramine, Maprotiline, Protriptyline, Timipramine, Doxepin, Amoxapine -may take 7-28 days to be effective. · Weight gain, sedation, nausea, anticholinergic symptoms (dry mouth, blurred vision, urinary retention, Constipation, tachycardia), orthostatic hypotension · special considerations: cardiotoxic side effects, avoid alcohol and herbal medications, or birthcontrol · Withdraw syndrome: restlessness, night sweats -Lethal OD, don't double up on doses.

1st generation antipsychotics

-1st generation antipsychotics: aka conventional, standard, traditional, typical, neuroleptics, dopamine antagonists, D2 receptor antagonists. In the 1940s these drugs got people out of forced seclusion and they could be with their families again. They target the positive S/S. Have an increased number of SE, especially EPS (extrapyramidal symptoms). -Examples:· High potency: trifluoperazine (generic only), thiothixene (Navane), fluphenazine (Prolixin), haloperidol (Haldol, this is still used frequently), pimozide (Orap). · Medium potency: loxapine (Loxitane), molidone (Moban), perphenazine (Trilafon). · Low potency: chlorpromazine (thorazine, one of the 1st in its class), thioridazine (Mellaril)

2nd generation antipsychotics

-2nd generation antipsychotics: aka atypical, serotonin-dopamine antagonists. Target positive and negative S/S, have fewer side effects, can treat depression, anxiety, and decrease suicidal behavior.Examples: aripiprazole (Abilify), clozapine (Clozaril, higher propensity for causing agranulocytosis), olanzapine (Zyprexa), paliperidone (Invega), quetiapine (Seroquel), risperidone (Risperdal), ziprasidone (Geodon, can cause an elongated QT interval, if patient has a heart problem, tell the Dr, they may need to be put on a monitoring device). -Can cause all the same adverse effects that that the 1st generation cause, but many have fewer EPSs and anticholinergic effects at lower doses. -Metabolic Syndrome: weight gain, dyslipidemia, and altered glucose (monitor glucose closely if patient has DM). Risk of DM, HTN, atherosclerosis, and increase in heart disease.-These drugs are more expensive that the 1st generation antipsychotics.

-Assaultive Stage: seclusion, restraint, meds, reintegration

-Assaultive Stage: -Seclusion: involuntary confined to a room, physically prevented from leaving. Must monitor them 1 on 1 for at least 1st hr. Then monitor every 15min, <14yrs constant monitoring. -Restraint: any manual method, physical or mechanical device, or material or equipment that restricts freedom of movement. Least restrictive first. HCP must come and see patient within 1-2hrs. -Medication: IM of barbiturate, antihistamine, or antipsychotic, depending on physicians order and underlying conditions. If willing to take meds, give PO and remove them from stimuli. -Gradual reintegration or structured reintegration (4pt to 2pt restraints, time out periods, gradually lengthened)

S/S of the 4 types of child abuse: Physical, Neglect, Sexual, Emotional/psychological

-Children younger than 4yrs are more vulnerable, as the child increases in age and physical size the abuse tends to lessen. -S/S of Physical Abuse: broken bones, spiral fractures, bruises/wounds in various stages of healing, bald patches on scalp, retinal hemorrhage, subdural hematoma (<2yrs old), shaken baby syndrome, death. Nightmares, anxiety, fear of parents or adults, withdrawn, aggressive, regressive behavior. Stories that don't 'add up'. -S/S of Neglect: Physical-malnourished, poorly clothed, living in squalor, poor growth, poor hygiene. Educational- not enrolled in school, school problems or failure. Arrives early or stays late at school, substance abuse, begging/stealing food, truancy/delinquency. Overindulgence is also a form of neglect, results in obesity. -S/S of Sexual Abuse: difficulty walking or sitting, frequent UTIs, bruising or bleeding in genital area, bloody or torn undergarments. Mental disorders, running away, advanced sexual knowlege/behaviors. -S/S of Emotional/Psychological Abuse: speech disorders, lag in physical development, infantile or adult-like behavior, dramatic behavioral changes, poor social skills.

Communication Guidelines/therapeutic strategies for schizophrenia:

-Communication Guidelines/therapeutic strategies for schizophrenia: lower their anxiety, decrease their defensive patterns, encouraging participation in therapeutic/social events, raising their feelings of self-worth, and increasing medication compliance. -When the patient is responding to internal stimuli: · Wait longer for the person to think about or process your questions and then respond, especially during the acute phase. · Repeat questions or gently redirect the person when necessary. · Use shorter phrases and concrete language to facilitate more effective communication. -With auditory hallucinations: the nurse should initially try to understand what the voices are saying or telling the person to do. Suicidal or homicidal (harm to others) messages require the nurse to initiate safety measures. · In acute phase, make eye contact with the patient, address them by name, and speak simply. Then suggest a reality-based activity, ex playing cards. · Empathize, identify the feelings the patient is experiencing, clarify, ask them to turn away from the voices, distract attention, and focus on a reality-based activity as a distraction technique.

-Disulfiram (Antabuse) -Acamprosate (Campral) -Naltrexone (ReVia, Vivitrol ER)

-Disulfiram (Antabuse): Aversion therapy--Ingested in combination with alcohol (1/4oz+) will cause N/V, headache, and flushing (an acetaldehyde reaction). Helps prevent relapse by discouraging impulsive drinking. Patient must be alcohol-free for at least 14 days. No alcohol, aftershave, hand sanitizer, mouthwash--up to 14 days after discontinuing med. -Acamprosate (Campral): Decreases longer-term unpleasant effects of withdrawal, including anxiety and restlessness. Diminishes alcohol cravings. -Naltrexone (ReVia, Vivitrol ER): Diminishes alcohol cravings, Blocks the effects of opiates, Useful in the acute recovery phase of alcohol dependence (first 12 weeks). Can precipitate narcotic withdrawal in patients using opioid drugs or pain medication

Lithium

-LITHIUM is the first line treatment for acute mania, acute bipolar depression, & in prevention of maniac and depressive episodes. Good for treatment resistant depression. It has significant anti switch side effects. -3 to 6 weeks to show a full therapeutic response, therapeutic serum levels in treating acute mania 0.5 to 1.2, maintenance 0.6 to 1.0, toxic concentrations greater than 1.5, draw at trough level 10 to 12 hours after the last dose, Monitor F/E because imbalances will cause a stronger concentration -Kidney function should be assessed before treatment and then yearly (creatinine, BUN, and GFR. • Thyroid-stimulating hormone (TSH) should be measured to determine thyroid dysfunction (goiter) before treatment and then yearly. -Excessive sweating, dehydration, & high sodium intake can increase levels. Patients living in hot/dry areas need to be careful with dehydration because this can quickly cause the serum lithium to increase to toxic levels. · Expected SE: (<0.4 - 1.0) fine hand tremor, polyurea, mild thirst, mild nausea, weight gain, acne, cognitive problems, hair loss -Interventions: give with food to decrease nausea, diet, exercise, and nutritional management for weight gain

-Manic Episode -Hypomanic Episode -Depressive Episode -Cyclothymic Disorder -Rapid-Cycling -Mania/hypomania with mixed features

-Manic Episode - DIGFAST: Distractibility, Impulsivity, Grandiosity, Flight Of Ideas/Racing Thoughts, Activity/Energy Increase, Sleep Needs Diminished(not tired after 3hrs sleep), Talkative -Hypomanic Episode: Less severe & intense form of mania, must last at least 4 days. -Depressive Episode: feeling of hopelessness and sadness, inability to sleep, loss of interest, loss of energy , changes in appetite and weight, inability to concentrate, thoughts of death and suicide. Patients with bipolar depression are less likely to be female. -Cyclothymic Disorder: psychodynamic disorder presents with hypomanic episodes alternating with persistent depressive episodes for at least two years or one year in children. Tend to have irritable hypomanic episodes. -Rapid-Cycling: 4+ mood episodes in 2 month period, reduces function and increases resistance to treatment. -Mania/hypomania with mixed features: S/S of depression and mania/hypomania occur at the same time. Increases suicide risk, irritability, pessimism, unrelenting worry/despair, reduced need for sleep.

-Mild anxiety -Moderate -Panic

-Mild anxiety: normal experience of everyday living. Perception is brought into sharp focus, problem solving becomes more effective. Physical symptoms such as restlessness, mild irritability, or mild tension-relieving behaviors such as nail biting and finger tapping may be present. -Moderate: perceptual field narrows, leading to selective inattention, learning and problem solving can still take place. Physical symptoms may include tension, pounding heart, increased pulse and respiration, and other mild somatic symptoms. Voice tremors may be noticed. -Severe: perceptual field is greatly reduced. The person may have difficulty noticing events occurring in the environment, even when they are pointed out. Learning and problem solving are greatly reduced. Behavior is automatic and aimed at reducing anxiety. Increased somatic symptoms, esp. hyperventilation and a sense of dread or impending doom. -Panic: the most extreme and results in markedly disturbed behavior. An individual is not able to process events in the environment and may lose touch with reality. Confusion, shouting, screaming, or extreme withdrawal. Possible hallucinations, erratic and impulsive behavior. Automatic behaviors are used to relieve anxiety, efforts may be ineffective. Acute panic may lead to exhaustion. The fight-or-flight response, "freeze" response(may loose memory), pass out, or dissociate.

Interventions for mild to moderate anxiety

-Mild to moderate anxiety: 1. Identify anxiety. "You look upset." 2. Assess the patient's level of anxiety. 3. Use nonverbal language to demonstrate interest (lean forward, maintain eye contact, nod your head). 4. Encourage the patient to talk about feelings and concerns. 5. Avoid closing off avenues of communication that are important for the patient. Focus on the patient's concerns. 6. Ask questions to clarify what is being said. "I'm not sure what you mean. Give me an example." 7. Help the patient identify thoughts or feelings before the onset of anxiety. "What were you thinking right before you started to feel anxious?" 8. Encourage problem solving with the patient. The person may need some assistance with this. 9. Assist in developing alternative solutions to a problem through role-play or modeling behaviors. 10. Explore behaviors that have worked to relieve anxiety in the past.11. Provide outlets for dissipating excess energy (walking, exercising).

MAOI's

-Monoamine oxidase inhibitors (MAOIs): drugs that increase concentrations of monoamines by inhibiting the action of MAO. Ex. Isocarboxazid, Phenelzine, Tranylcypromine, Selegiline (comes in transdermal patch form for treatment of depression) • Contraindications: stroke, HTN, CHF, liver dz, multi-med use, surgery in past 10-14 days, headaches, consuming foods with tyramine/tryptophan/dopamine, <16 yrs old. • Common side effects include sedation, weakness, fatigue, weight gain, sexual dysfunction, muscle cramps, and cardiac rhythm problems. • Hypotension is the most critical side effect, especially in the elderly (increased fall risk). • Tell the patient to go to the emergency department immediately if a severe headache, chest pain, and severe nausea and vomiting develop from a drug-drug or food-drug reaction. These symptoms may indicate a medical emergency: hypertensive crisis. • Monitor the patient's blood pressure for both hypotensive and hypertensive effects. • Instruct the patient that dietary and drug restrictions should be maintained for 14 days after discontinuing MAOIs. • Patients should be advised to tell their health care professional that they are taking an MAOI before starting any other over-the-counter or prescription medication.

-Phobias -Specific phobias -Social Anxiety Disorder or social phobias (SAD) -Agoraphobia

-Phobia: persistent, intense irrational fear of an object, activity, or situation that leads to a desire for avoidance, or actual avoidance of the object, activity, or situation. -Specific phobias: characterized by the experience of high levels of anxiety/fear in response to specific objects, such as dogs, spiders, or heights, or situations, such as closed spaces, tunnels, and bridges. Common and usually do not cause much difficulty because people can avoid the feared object. May cause impairment in social, occupational, or other areas of functioning when faced with the feared object or situation. -Social anxiety disorders or social phobias (SAD): characterized by severe anxiety or fear provoked by exposure to a social situation or a performance situation, resulting in feelings of humiliation or embarrassment. -Agoraphobia is an intense, excessive anxiety about or fear of being in places or situations where help might not be available, and escape might be either difficult or embarrassing. Avoidance may cause social/occupational dysfunction.

-Psychopharmacology for Alcohol Withdrawal

-Psychopharmacology for Alcohol Withdrawal: -Most common drug class used for alcohol withdrawal id Benzodiazepines. Provides sedation, decreases anxiety and feelings of tremulousness and decreases the risk of seizures. -Barbiturates (Phenobarbital): Can be given when patient not responding to Benzodiazepines. -Anti-Convulsants; can be used as adjunctive therapy to decrease anxiety and prevent seizures -Clonidine is a beta adrenergic blockade drug but is not useful for other symptoms of withdrawal. -Folic acid (folate, B9) and cyanocobalamin (vitamin b12) can correct megaloblastic anemia, and cyanocobalamin can halt peripheral neuropathy. -Thiamine (B1), magnesium, and Beta Blockers may also be given. -Chronic alcoholics are at risk of bleeding.

Interventions for severe to panic levels of anxiety

-Severe to Panic: 1. Maintain a calm manner. 2. Always remain with the person experiencing an acute severe to panic level of anxiety. 3. Minimize environmental stimuli. Move to a quieter setting and stay with the patient. 4. Use clear and simple statements. You may need to repeat statements. 5. Use a low-pitched voice; speak slowly. 6. Reinforce reality if distortions occur (seeing objects that are not there or hearing voices when no one is present). 7. Listen for themes in communication. 8. Attend to physical and safety needs when necessary (need for warmth, fluids, elimination, pain relief, family contact). 9. Because safety is an overall goal, physical limits may need to be set. Speak in a firm, authoritative voice: "You may not hit anyone here. If you can't control yourself, we will help you." 10. Provide opportunities for gross muscle motor movement and exercise (walk/pace with nurse). 11. When a person is constantly moving or pacing, offer high-calorie fluids. 12. Assess need for medication.

-Side Effects of Antipsychotics

-Side Effects of Antipsychotics: · Anticholinergic: urinary retention, constipation, dry mouth, blurry vision, tachycardia · Cardiovascular events: QTc interval prolongation and sudden death. Myocarditis and cardiomyopathy. Orthostatic hypotension. · Extrapyramidal side effects (EPSs) · Neuroleptic malignant syndrome (NMS) · Weight gain, Drug-induced liver disease, Cataracts, Photophobia, Seizures from lowered threshold, Sedation/somnolence, Blood dyscrasias such as agranulocytosis (red bone marrow doesn't make mature WBCs, cant fight infection) · ↑ Prolactin elevation: Gynecomastia, galactorrhea, menstrual problems · Hypersensitivity: skin rash· Sexual problems, Nausea and vomiting. -Contraindicated use in elderly with dementia. Cardiovascular or infection complications

Interventions for Phobias

-Specific Phobias: behavioral therapy seems to be the only effective therapy for specific phobias. Medication is not an effective treatment. -Social Phobias: The beta blocker propranolol reduces the physiological symptoms of anxiety, although not the cognitive worry symptoms. Propranolol is used effectively by many performers and lecturers before appearing in front of an audience. More pervasive social anxiety may respond to antidepressant therapy, such as SSRIs. CBT interventions, along with social skills training, are helpful for many. -Agoraphobia: The disorder can be chronic, although it responds well to CBT. Antidepressants, such as SSRIs, help reduce the anxiety and can treat comorbid depression. Panic attacks may precede agoraphobia 30% to 50% of the time.

CIWA for alcohol withdrawals

-The Clinical Institute Withdrawal Assessment for Alcohol Revised (CIWA-Ar)-It is a scale that provides an efficient (less 5 minutes) validated and objective means of assessing alcohol withdrawal symptoms that can then be utilized in treatment protocols (it guides treatment). -Assess 10 different categories of symptoms and to rate each symptom on a scale of 0 (not present) to 7 (extreme) -A complete set of vital signs plus the assessment is generally performed every 4 hours or as needed, -A score correlates to the severity of alcohol withdrawal. It can be used in any setting whenever there is a suspicion of AUD and potential alcohol withdrawal.

MAOI's and dietary restrictions

-The MAOIs inhibit the breakdown of dietary tyramine in the liver. Increased levels of tyramine can lead to high blood pressure, hypertensive crisis, and potentially a cerebrovascular accident (stroke) and death. -DO NOT ingest anything with tyramine: Ginseng, caffeinated beverages, avocados, fermented bean, soybeans, fava, sauerkraut, figs, bananas in large amounts, aged/spoiled meats, liver, fermented varieties, pickled herring and 'smoked salmon, dried, pickled, or Cured fish, all cheeses, East extract, beers, wines, Chianti, protein dietary supplements, soaps, shrimp paste, soy sauce, TURKEY

Antidepressant adverse effect: Serotonin Syndrome

Antidepressant adverse effect: Serotonin Syndrome: -Use the S∗H∗I∗V∗E∗R∗S memory tool to help you recognize the symptoms of serotonin syndrome: • Shivering • Hyperreflexia and myoclonus; muscular rigidity only in more severe cases • Increased temperature, usually only in severe cases; likely caused by muscular hypertonicity • Vital sign instability, presenting as tachycardia, tachypnea, and/or labile blood pressure • Encephalopathy—mental status changes such as agitation, delirium, and confusion • Restlessness and incoordination—common because of excess serotonin activity • Sweating (diaphoresis)—an autonomic response to excessive serotonin stimulation-Severe manifestation can induce hyperpyrexia (excessively high fever), cardiovascular shock, or death.

Bipolar Disorder: I & II

Bipolar Disorder: -Unusual shifts in mood, energy, and activity levels leading to difficulties in carrying out day-to-day tasks. Recurring depression and or recurrent elevated, expansive, and irritable moods - mania. -BDS are normally conceptualize as a bridge between depressive disorders and schizophrenic spectrum disorders in terms of symptoms, family history, and genetics. -It can also be a mixed episode, having both depression and mania. · The initial presentation of this disorder for men is usually mania, for females it is depression. -Bipolar spectrum disorders: -BIPOLAR I DISORDER: at least one episode of mania, accompanied by changes in activity & energy. Psychosis may be present with the manic or depressive episode. -BIPOLAR II DISORDER: at least one period of hypomania alternating with one or more periods of depression. Never experience a full manic episode. A decrease need for sleep & a lot of daytime fatigue are the red flags for hypomania.

Anticonvulsant Mood Stabilizers: -Carbamazepine (Tegretol) -Valproate, divalproex sodium (Depakote), and valproic acid (Depakene) -Lamotrigine (Lamictal)

1. Carbamazepine (Tegretol) is less effective than lithium and causes more side effects than valproate, but it may be better in rapid-cycling bipolar disorder. -It makes neurons less excitable in acute mania by stabilizing the inactive state of sodium channels in neurons. -A complete blood count (CBC) must be done periodically because of rare but serious blood dyscrasias (e.g., aplastic anemia and agranulocytosis). -It can also cause SJS, sexual dysfunction, and heart dysrhythmias. 2. Valproate, available as divalproex sodium (Depakote) and valproic acid (Depakene), is helpful in patients with bipolar disorder who are unresponsive to lithium. It possibly works by inhibiting enzymes involved in GABA catabolism, thereby inhibiting neuronal excitability. -Black Box warnings include hepatotoxicity, teratogenicity, and pancreatitis. Because of the potential for causing birth defects, women of childbearing age should use effective birth control methods while taking valproate. -Valproate increases the concentrations of another mood stabilizer, lamotrigine (Lamictal). 3. Lamotrigine (Lamictal) is effective in bipolar depression, lamotrigine inhibits the release of glutamate and aspartate. Lamotrigine may trigger a severe skin reaction called Stevens-Johnson syndrome (SJS).

-Children on antidepressants: -Older Adults on antidepressants:

Children on antidepressants: -There is the possibility that children, adolescents, and young adults taking antidepressants, particularly SSRIs, may experience both suicidal ideation and aggressive behaviors as side effects. A recent analysis of the most commonly prescribed antidepressants revealed that these drugs could double the risk of suicide and aggressive behavior in those under 18 years old. -There is a Black Box warning associated with all antidepressants for the increased risk of suicide in children and adolescents, but no formal mention of aggressive behavior. Monitor very closely for the first 9 days, and continue in the next few weeks. Older Adults on antidepressants: -The accepted practice for older adults is always, "Start low, go slow." Take into consideration the SE profile and the risk of drug-drug interactions. Doses must be adjusted. Due to slowed renal function associated with aging, the risk of hyponatremia is higher when using SSRIs and some of the newer antidepressants. Some antidepressants with long half-lives should be avoided in this population because of generalized slow drug metabolism.

Critical incident debriefing

Critical incident debriefing- Staff analysis of an episode of violence -First, a review is necessary to ensure that quality care was provided to the patient. Staff members need to critically examine their response to the patient. ---What could we have done to prevent this? Why was it not done? Did we act as a team? Did we follow protocol? Do we need to better educate the staff? How does the staff feel about the patient now? Feelings of fear/anger must be handled, so the patient wont be treated in a punitive and non-theraputic manner. -Second, the effects of workplace violence do not disappear after the incident is over, and the harm is not only to the individual assaulted. At times some nurses and staff may internalize (depression, avoidance, withdrawal) or externalize (anger, outbursts, fluctuating mood) their emotional and behavioral responses to the event. -Agencies need to provide support and debriefing to prevent long-term psychological sequelae. -Staff members must feel supported by their peers as well as by the organizational policies and procedures established to maintain a safe environment.

Cues of suicidal ideation: behavioral and verbal (overt and covert)

Cues of suicidal ideation: behavioral and verbal (overt and covert) -Behavioral Clues: Giving away prized possessions, Writing farewell notes, Making out a will, Putting personal affairs in order, Having global insomnia, Exhibiting a sudden and unexpected improvement in mood after being depressed or withdrawn, Neglecting personal hygiene -Verbal Clues: -Overt statements: "I can't take it anymore.", "Life isn't worth living anymore.", "I wish I were dead.", "Everyone would be better off if I died." -Covert statements: "It's okay now. Everything will be fine.", "Things will never work out.", "I won't be a problem much longer.", "Nothing feels good to me anymore, and probably never will.", "How can I give my body to medical science?"

Delirium

Delirium: -OnsetSudden: over hours to days -Cause or contributing factors: Hypoglycemia, fever, and dehydration, hypotension; infection, other conditions that disrupt the body's homeostasis; adverse drug reaction; head injury; change in environment (e.g., hospitalization); pain; emotional stress;B12 and folate deficiencies -Cognition: Impaired memory, judgment, calculations, and attention span; can fluctuate throughout the day -Level of consciousness: Altered -Activity level: Can be increased or reduced; restlessness; behaviors may worsen in evening (sundown syndrome); sleep-wake cycle may be reversed -Emotional state: Rapid swings; can be fearful, anxious, suspicious, and aggressive and have hallucinations and/or delusions. Hypervigilant, ANS hyper. -Speech and language: Rapid, inappropriate, incoherent, rambling -Prognosis: Reversible with proper and timely treatment

Delusions

Delusions: reflect a distortion in thought content. · Clarify the reality of the patient's experience and empathizes with the patient's apparent experience and feelings of fear. Avoid being drawn into the conversation regarding the content of the delusion but attempt to identify the feelings that the patient is experiencing. Talking about the person's feelings is helpful; talking about delusional material is not. Clarify misinterpretations of the environment, but do not try to reason/argue with them. Use distraction and reality-based activities.

Dementia

Dementia: -Onset: Slowly, over months to years -Causes: Alzheimer's disease(tau protein changes, fibrillary tangles, enlarged ventricles, Senile plaques-beta amyloid), vascular disease, human immunodeficiency virus infection, neurological disease, chronic alcoholism, head trauma, B12 and folate deficiencies -Cognition: Impaired memory, judgment, calculations, attention span, and abstract thinking; agnosia -LOC: Not altered -Activity: Not altered; behaviors may worsen in evening (sundown syndrome) -Emotion: Flat affect, suspiciousness, catastrophic reactions, anxiety, anger, aggressiveness -Speech/language: Incoherent, slow (sometimes due to effort to find the right word), inappropriate, rambling, repetitious -Prognosis: Not reversible; progressive

Depression

Depression: -Onset: May have been gradual with exacerbation during crisis or stress -Cause: Lifelong history, losses, loneliness, crises, declining health, medical conditions -Cognition: Difficulty concentrating, forgetfulness, inattention -LOC: Not altered -Activity: Usually decreased; lethargy, fatigue, and lack of motivation; may sleep poorly and awaken in early morning -Emotion: Extreme sadness, apathy, irritability, anxiety, paranoid ideation -Speech/language: Slow, flat, low -Prognosis: Reversible with proper and timely treatment

-Emergency Measures for Serotonin Syndrome

Emergency Measures for Serotonin Syndrome: 1. Discontinue offending agent(s); call health care practitioner immediately. 2. Initiate symptomatic treatment per orders:• Muscle relaxants. Benzodiazepines can help control agitation, seizures, and muscle stiffness; (and /or) dantrolene for muscle relaxation. • Serotonin-production blocking agents, such as cyproheptadine, can help by blocking serotonin production. • Oxygen and intravenous (IV) fluids. O2 helps maintain normal oxygen blood levels, and IV fluids treat dehydration and fever. • Drugs that control heart rate and blood pressure. These may include the following: • Esmolol (Brevibloc) or nitroprusside (Nitropress), to reduce increased heart rate or high blood pressure • Phenylephrine (Neo-Synephrine) or epinephrine (Adrenalin, EpiPen) for hypotension • Cooling blankets for high fever • Use of a breathing tube and machine and medication to paralyze muscles

Healthy defense mechanisms: -Altruism -Sublimation -Humor -Suppression

Healthy defense mechanisms: -Altruism: In altruism, emotional conflicts and stressors are addressed by meeting the needs of others. Unlike self-sacrificing behavior, in altruism, the person receives gratification either vicariously or from the response of others. -Sublimation: is an unconscious process of substituting constructive and socially acceptable activity for strong impulses that are not usually considered acceptable. Often these impulses are sexual or aggressive. A man with strong hostile feelings may choose to become a butcher, or he may participate in rough contact sports. -Humor: makes life easier. An individual may deal with emotional conflicts or stressors by emphasizing the amusing or ironic aspects of the conflict or stressor through humor. -Suppression: is the conscious denial of a disturbing situation or feeling.

Immature defense Mechanisms: -Passive Aggression -Acting-Out Behaviors -Dissociation -Devaluation -Idealization -Splitting -Projection -Denial

Immature defense Mechanisms: -Passive Aggression: dealing with emotional conflict or stressors by indirectly expressing aggression toward others. -Acting-Out Behaviors: individual addresses emotional conflicts or stressors by actions rather than by reflections or feelings--to distract the self from threatening thoughts or feelings. It's a destructive coping style. -Dissociation: A disruption in the usually integrated functions of consciousness, memory, identity, or perception of the environment. -Devaluation: occurs when emotional conflicts or stressors are handled by attributing negative qualities to self or others--the individual then appears good by contrast. -Idealization: emotional conflicts or stressors are addressed by attributing exaggerated positive qualities to others. -Splitting: inability to integrate the positive and negative qualities of oneself or others into a cohesive image. Prevalent in PDs, esp. BPD. -Projection: person unconsciously rejects emotionally unacceptable personal features in one's self and attributes those unacceptable traits to other people, objects, or situations through projection. -Denial: involves escaping unpleasant realities by ignoring their existence. ----Denial, splitting, and acting out are all very negative coping mechanisms for a patient to exhibit.

Intermediate Defense mechanisms: -Repression -Displacement -Reaction Formation -Somatization -Undoing -Rationalization

Intermediate Defense mechanisms -Repression: is the exclusion (forgetting) of unpleasant or unwanted experiences, emotions, or ideas from conscious awareness. It is considered the cornerstone of the defense mechanisms, and 1st line of psychological defense against anxiety. -Displacement: Transfer of emotions associated with a specific person, object, or situation to another person, object, or situation that is nonthreatening -Reaction Formation: unacceptable feelings or behaviors are kept out of awareness by developing the opposite behavior or emotion. -Somatization: repressed anxiety is demonstrated in the form of physical symptoms that have no organic cause. -Undoing: performing an action to make up for a previous behavior. Example: giving a gift to "undo" an argument. A pathological example of undoing is compulsive hand washing--cleansing oneself of an act or thought perceived as unacceptable. -Rationalization: justifying illogical or unreasonable ideas, actions, or feelings by developing acceptable explanations for the behavior. It is a form of self-deception.

Interventions for Acute Mania: Nutrition, Sleep/rest, Hygiene, Elimination

Interventions for Acute Mania: Safety/Physical Needs --Nutrition 1. Monitor intake, output, and vital signs. (Cardiac collapse) 2. Offer frequent high-calorie protein drinks and milkshakes and finger foods such as sandwiches and fruit. 3. Frequently remind patient to eat. "Tom, finish your milkshake." "Sally, eat this banana." --Sleep/Rest 1. Encourage frequent rest periods during the day. 2. Keep patient in areas of low stimulation. 3. At night, provide warm baths, soothing music, and medication when indicated. Avoid giving patient caffeine. --Hygiene 1. Supervise choice of clothes; minimize flamboyant and bizarre clothing, such as unmatched colors or sexually provocative clothing. (Maintain dignity) 2. Give simple, step-by-step reminders for hygiene and dress. "Here is your razor. Shave the left side ... now the right side. Here is your toothbrush. Put the toothpaste on the brush." --Elimination 1. Monitor bowel habits; offer fluids and foods that are high in fiber. Evaluate need for laxative. Encourage patient to go to the bathroom.

Modified CAGE Questionnaire

Modified CAGE Questionnaire: □ Have you ever felt you should Cut down on your drinking or drug use? □ Have people Annoyed you by criticizing your drinking or drug use? □ Have you ever felt bad or Guilty about your drinking or drug use? □ Have you ever had a drink or used a drug first thing in the morning to steady your nerves or to get rid of a hangover (Eye opener)? Scoring: Positive responses are given 1 point. A score of 2 or more is considered clinically significant. -AID: Adapted to Include Drugs

Modeling, Aversion therapy, Flooding, Systematic desensitization, ERP, Thought Stopping

• Modeling —the patient learns new skills by imitating another person, such as a parent or therapist, who performs the behavior to be acquired. It can include "imitating" more adaptive responses to an anxiety-provoking situation. • Aversion therapy —during this therapy, an undesirable behavior is associated with an unpleasant stimulus. (Ex Antabuse). The smell of alcohol produces a memory of vomiting, which stops the desire to drink again. Relapse rates with this technique are high. • Flooding —uses prolonged exposure to a feared object or situation. The initial fear response is replaced with exhaustion and decreased anxiety levels. This therapy is rarely used but can be effective in very specific cases. • Systematic desensitization —sometimes called "exposure therapy"; involves gradually exposing a person to a feared object or situation until the person is free of incapacitating anxiety. This therapy is especially helpful with phobias. • Exposure and response prevention (ERP )—this technique is designed to systematically desensitize people to their fears. By repeatedly facing fears and learning to manage the uncomfortable feelings and thoughts associated with these fears, the patient learns to allow the anxiety to gradually fade. (treat ritualistic acts of OCD) • Thought stopping— this is a cognitive strategy to get rid of unwanted stressful thoughts. It involves (1) ID a stressful thought, (2) focusing on that thought, (3) actively interrupting the thought by performing a behavior (ex snap rubberband, say "stop") until the thought goes away.

Pre-Assaultive Phase interventions--Deescalation

Pre-Assaultive Phase interventions--Deescalation: 1. Pay attention to angry and aggressive behavior. Respond as early as possible and reduce stimuli. 2. Emphasize that you are on the patient's side (e.g., "We want to help you, not hurt you.") and that "this is a safe place and you are safe." The clinician should stand at an angle to the patient so as not to appear confrontational. 3. Assess personal safety and provide for self-care. 4. Appear calm and in control, use "show of force" 5. Do not try to speak while the aggressive person is yelling. 6. Speak softly in a nonprovocative, nonjudgmental manner. 7. Demonstrate genuineness and concern. 8. Set clear, consistent, and enforceable limits on behavior (e.g., "It's okay to be angry with Tom, but it is not okay to threaten him. If you are having trouble controlling your anger, we will help you."). 9. If patient is willing, both nurse and patient should sit at a 45-degree angle. Do not tower over or stare at the patient. 10. When patient begins to talk, listen. Use clarification. 11. Acknowledge the patient's needs regardless of whether the expressed needs are rational or irrational, possible or impossible to meet.

Therapy for the older adult: -Remotivation therapy -Reminiscent therapy -Psychotherapy

Remotivation therapy- Re-socialize regressed and apathetic patients. Reawaken interest in the environment. Groups are made up of 10 to 15 people. Outcome- Increase participants' sense of reality. Offer practice of health roles. Realize more objective self-image than older adult can. Reminiscent therapy (life review)- Share memories of the past, Increase self-esteem, Increase socialization, Increase awareness of the uniqueness of each participant. Groups are made up of 6 to 8 people. Alleviate depression in institutionalized older adult. Through the process of reorganization and reintegration, provide avenue by members, Achieve a new sense of identity, Achieve a positive self-concept. Psychotherapy- Alleviate psychiatric symptoms, Increase ability to interact with others in a group, Increase self-esteem, Increase ability to make decisions and function more independently. Group size is 6 to 12 members. Group members should share similar: Problems, Mental status, Needs, Sexual integration. Outcome- Decrease sense of isolation, Facilitate development of new roles and re-establish former roles, Provide information for other group, Provide group support for effecting changes and increasing self-esteem.

S/S of a patient who is beginning to escalate

S/S of a patient who is beginning to escalate: -The first 4hrs on the MHU are the "Golden hrs", more likely to be violent, the flowing 20hrs are the "brown hrs". Monitor closely for first 24hrs. 1. Signs and symptoms that usually (but not always) precede violence: it could be spontaneous--Angry, irritable affect, Hyperactivity: most important predictor of imminent violence (e.g., pacing, restlessness, slamming doors), Increasing anxiety and tension: clenched jaw or fist, rigid posture, fixed or tense facial expression, mumbling to self (patient may have shortness of breath, sweating, and rapid pulse rate), Verbal abuse: profanity, argumentativeness, Loud voice, change of pitch, or very soft voice forcing others to strain to hear, Intense eye contact or avoidance of eye contact 2. Recent acts of violence, including property violence 3. Stone silence 4. Suspiciousness or paranoid thinking 5. Alcohol or drug intoxication (withdrawal) 6. Possession of a weapon or object that may be used as a weapon (e.g., fork, knife, rock) 7. Milieu characteristics conducive to violence: Loud, Overcrowding, Staff inexperience, Provocative or controlling staff, Poor limit setting, Staff inconsistency (e.g., arbitrary revocation of privileges)

Trazodone (Desyrel)

Serotonin Antagonists/Reuptake Inhibitors: -High doses are required for the serotonergic action of the serotonin antagonist/reuptake inhibitor (SARI) trazodone (Desyrel). -At lower doses, it loses its antidepressant action while retaining hypnotic effects through histamine receptor antagonism. -Although useful for insomnia, trazodone's potent α-adrenergic blocking properties can cause priapism (painful prolonged penile erections).

Stages of Alzheimer's

Stage 1 (Mild)-Forgetfulness: -Shows short-term memory loss; loses things, forgets Memory aids compensate: lists, routine, organization. Aware of the problem; concerned about lost abilities. Depression common—worsens symptoms. Disease is not diagnosable from the symptoms Stage 2 (Moderate)-Confusion: -Shows progressive memory loss; short-term memory impaired; memory difficulties interfere with abilities. Withdrawn from social activities. Shows declines in activities of daily living (ADLs), such as money management, legal affairs, transportation, cooking, housekeeping. Denial common; fears "losing one's mind". Depression increasingly common; frightened because aware of deficits; covers up for memory loss through confabulation. Problems intensified when stressed, fatigued, out of own environment, ill. Commonly needs day care, or in-home assistance is needed at this time. Apraxia, Labile mood. Stage 3 (Moderate to severe)-Ambulatory dementia: -Shows ADL deficits: willingness and ability to bathe, grooming, choosing clothing, dressing, gait and mobility, toileting, communication, reading, and writing skills. Shows loss of reasoning ability, safety planning, and verbal communication. Frustration common; becomes more withdrawn and self-absorbed. Depression resolves as awareness of losses diminishes. Has difficulty communicating; shows increasing loss of language skills. Shows evidence of reduced stress threshold; institutional care usually needed. Advanced agnosia and apraxia. Unable to ID objects/people. Stage 4 (Late)-End stage: -Family recognition may disappear; may not recognize self in mirror. Nonambulatory; shows little purposeful activity; often mute; may scream spontaneously. Forgets how to eat, swallow, chew; commonly loses weight; emaciation common. Has problems associated with immobility (pneumonia, pressure ulcers, contractures). Incontinence common; seizures may develop. Most certainly institutionalized at this point. Return of primitive (infantile) reflexes. Agraphia, hyperorality, hypermetamorphosis.

Stages of Alcohol Withdrawal Syndrome (AWS)

Stages of Alcohol Withdrawal Syndrome (AWS): 1. Early/Minor: Can occur 2 hr after stopping or reducing use, Usually develops within 7-48 hr, S/S usually peak after 24-48 hr. -Autonomic: elevated vital signs, diaphoresis, gastrointestinal symptoms, headache -Motor: Hand tremors, feeling shaky inside, jerky movement, ataxia, startle easily, irritability, seizures. 2. Moderate: Appears 7 to 48 hr after stopping or reducing use, Can continue for 5 to 7 days. -Worsening of above autonomic and motor symptoms Continued elevation of all vital signs, including temperature; vomiting; clammy skin -Psychiatric: Anxiety, mood lability, combativeness, hallucinations (auditory, visual, and tactile), illusions 3. Severe: Can start in the same time frame as above May progress to delirium tremens (DTs)--medical emergency, may be fatal. Peaks 2-3 days (48-72hrs) after cessation. S/S hallucination, delusion, agitation, fever(>100), perceptual/autonomic/sensorium disturbances, fluctuating LOC. -All of above symptoms plus seizures, Awareness Symptoms, Disorientation and confusion, Agitation and irritability, Paranoia and disinhibition.

Interventions for delusions

· 1. Assess if external controls are needed: if the patient is agitated and believes someone is going to inflict harm, the patient may harm someone else to survive; use safety measures. · 2. Be aware that the patient's delusions represent the way that person is experiencing reality. · 3. Identify feelings: · a. If the patient believes there is an attempt to "get" the patient, then the patient is experiencing fear. · b. If the belief is that someone is controlling the patient's thoughts, then the patient is experiencing helplessness. · 4. Engage the individual in yoga, exercise, walking, etc. · 5. Do not argue with the patient's beliefs or try to correct false beliefs with logic or facts. · 6. Do not touch the patient; use gestures very carefully, particularly if the patient is paranoid.

Lithium Toxicity

· Early Signs: (<1.5) increase nausea , vomiting, diarrhea, thirst, polyurea, slurred speech, muscle weakness -Interventions: hold medication, measure blood levels, re-evaluate dosage · Advanced signs: (1.5 - 2) course hand tremor , GI upset, confusion, muscle hyper-irritability, Electroencephalographic (EEG) changes, Incoordination. -Interventions: hold medication, measure blood levels, revaluate dosage, treat more serious symptoms · Severe Toxicity: (2 - 2.5) serious EEG changes, ataxia, blurred vision, clonic movements, large output of urine, tinnitus, blurred vision, seizures, stupor, severe hypotension, coma, death secondary to pulmonary complications -Interventions: there is no antidote, stop drug and facilitate excretion: if alert, give emetic, gastric lavage, treatment with urea, mannitol, and aminophylline to hasten excretion, Hemodialysis - >2.5 symptoms-may progress rapidly, coma, cardiac dysrhythmia, peripheral circulatory collapse, proteinuria, oliguria, and death-use interventions listed above + hemodialysis for severe cases.

· Extrapyramidal side effects (EPSs)

· Extrapyramidal side effects (EPSs): -Dystonias- severe spasms of the muscles of the tongue, head, and neck; fixed upward deviation of the eyes; and severe back spasms that arch the trunk forward and thrust the head and lower limbs backward -Akathisia- internal restlessness and external restless pacing or fidgeting; sometimes mistaken for psychotic agitation or comorbid anxiety -Parkinsonian symptoms- stiffening of muscular activity in the face, body, arms, and legs; salivation; shuffling gait; tremor; bradykinesia -Tardive dyskinesia (TD)- usually appears after prolonged treatment. TD consists of involuntary tonic muscular spasms of the face and jaw. TD is most frequently seen in older women and older patients and varies from mild to moderate. It can be disfiguring or incapacitating. -1st & 2nd generation can cause, but 1st generation have an increased risk. -Treating EPS: Catch it early! Lower the dose of the antipsychotic and prescribe anti-parkinsons drugs, ex Anticholinergic agent: trihexyphenidyl (Artane) or benztropine mesylate (Cogentin) or Dopamine agonist: amantadine hydrochloride (Symmetrel). Diphenhydramine hydrochloride (Benadryl). Biperiden (Akineton).

Neuroleptic(antipsychotic) malignant syndrome (NMS)

· Neuroleptic(antipsychotic) malignant syndrome (NMS): greatly increased muscle rigidity (with elevation in creatine phosphokinase [CPK]); elevated temperature; altered level of consciousness; and autonomic dysfunction, including labile (changeable) hypertension, tachycardia, tachypnea, diaphoresis, and drooling. -Symptoms Memory Tool F ∗ E ∗ V ∗E ∗ R: -Fever (Hyperpyrexia: >103°F or above 38°C) -Elevated CPK/WBC -Vital sign instability (autonomic instability): Fluctuating BP, pallor, tachycardia. Excessive sweating, salivation, tremors, incontinence. -Encephalopathy: Confusion, agitation, altered level of consciousness-Rigidity (Muscle)

Symptoms of Schizophrenia

· Positive symptoms are "add-on" symptoms, AKA "florid" symptoms. Some common "positive" symptoms seen in schizophrenia include hallucinations, delusions, bizarre behavior, catatonia, formal thought disorder, and paranoia. Echolalia (repeat anothers words) and Echopraxia (mimicking anothers movements) are often seen in catatonia. · Negative symptoms are "deficit" S/S, which include thoughts and behaviors that the individual no longer demonstrates. Apathy, lack of motivation, social withdrawal, and anhedonia. These S/S are harder to treat. They develop insidiously over a long period of time. Reduces quality of life and functioning. · Cognitive symptoms: the most debilitating S/S. These include impairment in memory, disruption in social learning, and a decreased ability to reason and solve problems or focus attention. · Impairment of insight is considered a hallmark of schizophrenia. It is associated with both cognitive and negative symptoms of the disease. Refers to their inability to recognize they have a disease, inability to label unusual psychological experiences as pathological, and nonadherance to treatment plan. · Mood symptoms: variations in mood, such as anxiety, depression, demoralization, agitation, excitability, suicidality, and dysphoria (a state of feeling emotionally unwell).